Judd, Marlea A.

Background: Sedation care documentation and patient safety on general care nursing units need improvement. Purpose: To assess the impact of implementation of a registered nurse sedation team model on patient safety and thoroughness of documentation in patients receiving moderate sedation on general care units. Methods: In 2010 a 3-month retrospective chart review determined adverse patient outcomes and incompleteness of documentation for patients receiving sedation on general care units. After implementation of the registered nurse sedation team model for 3 months, patient’s sedation documentation and outcomes were assessed. The registered nurse sedation team model was implemented into practice and further outcome data from implementation through 2017 also were assessed. Results: There was clear improvement in both required documentation during moderate sedation and patient safety (P<0.001). Conclusion: The registered nurse sedation team model in this study improved both completeness of required sedation documentation and patient safety.